1. THEORY

2. What is theory?  “… a set of interrelated concepts, definitions, and propositions that presents a systematic view of events or situations by specifying relationships among variables in order to explain and predict the events or the situations.”  (Glanz, Rimer, and Lewis, p. 25)

3. Theory  “Effective health promotion and education depends on practitioners’ marshaling the most appropriate theory and practice strategies for a given situation.”  “The gift of theory is that it provides conceptual underpinnings for well-crafted research and practice.” (Glanz, Rimer, & Lewis, pp. 30-31)

4. Theories are used to …  Guide the search for why people behave in certain ways  Help pinpoint information needed before developing and organizing an intervention program  Provide insight as to how to shape strategies to reach people  Help identify what should be monitored, measured, and compared

5. Concepts & Constructs  Concepts:  Major ideas  Constructs:  Concepts that have been developed and defined for use in a particular theory

6. More theory  “Habit is habit, and not to be flung out of the window, but coaxed downstairs a step at a time.”  Mark Twain

7. The Ecological Model  Emphasizes the links and relationships among multiple factors (or determinants) affecting health

8. Ecological Model Individual Interpersonal Institutional or Organizational Community Public Policy

9. Individual / Intrapersonal factors  Knowledge, attitudes, beliefs (KAB)  Skills  Motivation  Self-concept  Age, gender, genetics

10. Interpersonal factors  Social support / social networks  Formal and informal Family, friends, peers  Social norms, cultural environment

11. Institutional or organization factors  Social institutions with organizational characteristics and formal (and informal) rules and regulations for operations. (ACHA, 2012)

12. Community factors  The geographic, cultural or social community.  May include: Community organizations Local laws Physical characteristics/attributes of location Available (or unavailable) services

13. Public Policy Factors  Local, state, national and global laws and policies. (ACHA, 2012)  May promote or restrict behavior

14. Ecological Model ConceptDefinition Intrapersonal FactorsIndividual characteristics that influence behavior, such as knowledge, attitudes, beliefs, and personality traits. Interpersonal FactorsInterpersonal processes, and primary groups including family, friends, peers, that provide social identity, support, and role definition. Institutional/Organizational FactorsRules, regulations, policies, and informal structures, which may constrain or promote recommended behaviors. Community FactorsSocial networks and norms, or standards, which exist as formal or informal among individuals, groups, and organizations. Public PolicyLocal, state, federal policies and laws that regulate or support healthy actions and practices for disease prevention, early detection, control, and management. NIH, Theory at a Glance

15. Ecological Model Individual Interpersonal Institutional or Organizational Community Public Policy

16. Behavior Change Theories  The specific route(s) you will take to reach your destination – they suggest a road to follow.

17. Behavior change theories with individual focus  The Health Belief Model (HBM) **  The Transtheoretical Model (TTM) **  Theory of Planned Behavior (TPB) **  Other Theories:  Elaboration Likelihood Model of Persausion  Information – Motivation – Behavioral Skills Model  Health Action Process Approach

18. Health Belief Model (HBM)  Developed in the early 1950’s by social psychologists in the U.S. Public Health Service.  Hochbaum & Rosenstock  TB screening

19. Constructs of HBM  Perceived threat  Perceived susceptibility Beliefs about one’s chances of getting a condition  Perceived severity Beliefs about how serious the condition might be

20. Constructs of HBM  Outcome Expectations  Perceived Benefits Beliefs that the advised action will reduce risk or seriousness of the condition.  Perceived risks/barriers Beliefs about the “costs” of taking the advised action

21. Constructs of HBM  Cues to Action  Strategies to activate one’s “readiness”  Self-Efficacy  Confidence in one’s ability to take action

22. Health Belief Model Perceived Susceptibility & Perceived Seriousness Perceived Threat Likelihood of taking recommended action Cues to Action Modifying Factors: age, race, ethnicity, SES, personality Outcome Expectations: Perceived Benefits vs. Perceived Risks/Barriers Self-efficacy

23. Health Belief Model Strong family history of heart disease / strokes; feels it could “happen to him” and ultimately lead to serious disability/death Perceived Threat Likelihood of taking recommended action Doctor diagnosed him as hypertensive, started on medication 45 y/o Caucasian male, married, 2 children, works full- time, desk job, does not seek health information Outcome Expectations: Perceived benefits: no HTN medication, delay or prevent heart disease/stroke, live longer, better quality life. Perceived barriers/risks: time, money, injury? Self-efficacy: moderate

24. Health Belief Model ConstructDefinitionApplication Perceived Susceptibility One’s opinion of chances of getting a condition. Personalize risk based on a person’s feature or behavior; heighten perceived susceptibility if low. Perceived Severity One’s opinion of how serious a condition and its effects are. Specify consequences of the risk and the condition. Perceived Benefits One’s opinion of the efficacy of the advised action to reduce risk / seriousness of impact. Define action to take; how, where, when; clarify the positive effects to be expected. Perceived Barriers One’s opinion of the tangible and psychological costs of the advised action. Identify and reduce barriers through reassurance, incentives, assistance. Cues to ActionStrategies to activate “readiness”Provide how-to information, promote awareness, reminders. Self-EfficacyConfidence in one’s ability to take action. Provide training, guidance in performing action. NIH, Theory at a Glance

25. Theory of Reasoned Action (TRA)  Constructs:  Attitude toward the behavior Beliefs about the behavior Evaluation of behavioral outcomes  Subjective norms What others think about your behavior How motivated you are to comply with the expectations of others

26. TRA Cont.  Beliefs and Subjective Norms help predict Intentions  Your Intentions predict your actual Behavior

27. TRA Attitude toward behavior Subjective Norm IntentionBehavior

28. Theory of Planned Behavior (TPB)  Developed by Fishbein & Ajzen  An extension of the Theory of Reasoned Action (TRA)

29. TPB versus TRA  Adds the construct:  Perceived Behavioral Control Belief about personal control in combination with belief about the one’s ability to do what needs to be done. Actual Behavioral Control: have the skills and resources needed to quit.

30. TPB Cont.  People will perform a behavior if:  They believe the advantages of success outweigh the disadvantages of failure.  They believe that other people with whom they are motivated to comply, think they should perform the behavior.  They have sufficient control over the factors that influence success or ability to perform the behavior.

31. TPB Attitude toward the behavior Subjective Norm IntentionBehavior Perceived Behavioral Control Actual Behavioral Control

32. TPB Healthy eating takes time, extra money and a lot of energy Friends / family do not exercise and junk food is always abundant IntentionEating healthier/ exericse “Not much I can do” Nearby grocery stores often have good sales, lives near farmer’s market. Lives near park and walking trails

33. Theory of Planned Behavior ConstructDefinitionApplication / Approach Behavioral Intention Perceived likelihood of performing behavior Are you likely or unlikely to perform the behavior? AttitudePersonal evaluation of the behavior Do you see the behavior as good, neutral or bad? Subjective Norm Beliefs about whether key people approve or disapprove of the behavior; motivation to behave in a way that gains their approval Do you agree or disagree that most people approve of/disapprove of the behavior? Perceived Behavioral Control Belief that one has, and can exercise, control over performing the behavior Do you believe performing the behavior is up to you, or not up to you? NIH, Theory at a Glance

34. Transtheoretical Model (TTM)  AKA: Stages of Change  Developed by Prochaska & DiClemente  Major Constructs:  Precontemplation  Contemplation  Preparation  Action  Maintenance  Decisional Balance  Self-Efficacy

35. Precontemplation  “The shoes are still at the store”  Not thinking about changing behavior in the next six months.  May be unaware of risks or problems.  Needs some work “under the hood.”

36. Contemplation  “Shoe shopping”  Seriously thinking about making a behavior change, but have not yet made a commitment to action

37. Preparation  “You bought the shoes”  Ready to take action in the very near future (next 30 days)  Have a plan of action  Experimenting with new behaviors

38. Action  “Wearing your shoes on a regular basis”  Actively engaged in new behavior(s) for less than six months.  Efforts are sufficient to reduce risk of disease

39. Maintenance  “Shoes go on every day.”  Sustaining the behavior change for over 6 months.

40. Decisional Balance  The costs and benefits of changing.

41. Self-Efficacy  Confidence that one can be successful in the new behavior across different challenging situations.

42. Relapse  More likely when you are stressed, anxious, or feeling depressed.  More likely if you lack social support or are experiencing interpersonal conflicts  More likely if you return to a setting (environment) that “cues” your old behavior(s)

43. Precontemplation Contemplation Preparation Action Maintenance Decisional Balance Self-Efficacy Transtheoretical Model (TTM) Between every stage, the client needs to have decisional balance and self-efficacy

44. Stages of Change (TTM) ConstructDefinitionApplication Pre-contemplationUnaware of problem, hasn’t thought about change. Increase awareness of need for change, personalize information on risks and benefits. ContemplationThinking about change in the near future. Motivate, encourage to make specific plans. PreparationMaking a plan to change.Assist in developing concrete action plans, setting gradual goals. ActionImplementation of specific action plan. Assist with feedback, problem solving, social support, reinforcement. MaintenanceContinuation of desirable actions, or repeating periodic recommended step(s) Assist in coping, reminders, finding alternatives, avoiding relapses NIH, Theory at a Glance Groups with this theory: don’t forget a relapse plan!

45. Pro’s of TTM  Encourages less “labeling” terms.  (Precontemplation rather than “loser” or “lost cause”)  Must accept people “where they are”  Behavior change is not viewed as linear  It is easy to stage clients  It is not based on an instant gratification mentality  Allows for stage-matched interventions

46. How to stage a person using TTM Do you exercise regularly? No Yes Do you intend to in the next 30 days? Have you been doing so for more than 6 months? No YesNoYes Do you intend to in the next six months? No Yes Precontemplation Contemplation PreparationActionMaintenance (Pearson Ed, 2012)

47. Adapted from: Autobiography in Five Short Chapters by Portia Nelson I I walk down the street. There is a deep hole in the sidewalk. I fall in I am lost … I am helpless It takes forever to find a way out.

48. II I walk down the same street. There is a deep hole in the sidewalk. I pretend I don’t see it. I fall in again. I can’t believe I am in the same place. It still takes a long time to get out.

49. III I walk down the same street. There is a deep hole in the sidewalk. I see it is there. I still fall in … it’s a habit. My eyes are open. I know where I am. I get out immediately.

50. IV I walk down the same street. There is a deep hole in the sidewalk. I walk around it. V I walk down another street.

51. Behavior change theories with interpersonal focus  Social Cognitive Theory (SCT) **  Social Network Theory (SNT)  Social Capital Theory

52. Social Cognitive Theory (SCT)  A behavior change theory with an Interpersonal / Social network focus.

53. Reciprocal Determinism Characteristics of the Person Environment in which the behavior is performed Behavior of the person

54. More constructs of SCT  Behavior Capacity  Expectations  Expectancies  Self-Control / Self- Regulation  Self-Efficacy  Reinforcement  Observational Learning  Emotional Coping Responses

55. Reinforcement  Any action or event that increases the desired behavior  Present something positive Money New clothes  Remove something negative Nagging Teasing

56. Punishment  Any action or event that decreases the likelihood that the desired behavior will occur.  Present something negative Criticize Policies or laws  Remove something positive Praise Privilege

57. Social Cognitive Theory ConstructDefinitionApplication Reciprocal Determinism Behavior changes result from interaction between person and environment Involve the individual and relevant others; work to change the environment, if warranted. Behavioral Capacity Knowledge and skills to influence behavior Provide information and training about action. ExpectationsBeliefs about likely results of action Incorporate information about likely results of action in advice. Self-EfficacyConfidence in ability to take action and persist in the action Point out strengths; use persuasion and encouragement; approach behavior change in small steps. Observational Learning Beliefs based on observing others like self and/or visible physical results Point out others’ experience, physical changes; identify role models to emulate. ReinforcementResponses to a person’s behavior that increase or decrease the chances of recurrence Provide incentives, rewards, praise; encourage self-reward; decrease possibility of negative responses that deter positive changes. NIH, Theory at a Glance

58. Behavior theories with community focus  Diffusion of Innovation Theory (DF) **  AKA: Diffusion Theory  Community Readiness Model (CRM)

59. Diffusion of Innovations Theory  Rogers, 1983  A behavior change theory with a community focus

60. Diffusion of Innovations  The progressive adoption by members of a community or society of an idea or practice over time.

61. Adoption Curve

62. Categories of Adopters  Innovators (<3%)  Independent, risk-takers, eager to try new ideas  Not necessarily the most respected members of the community  Seek info on their own, rely on their own judgment in making decisions about adoption  Try out new ideas and provide the first tests of the utility of the innovation

63. Categories of Adopters  Early Adopters (14%)  Respected members of the community  Opinion leaders  Powerful influence on other potential adopters  Trendy … like to be up on what is good and new  Seen as opinion leaders

64. Categories of Adopters  Early Majority (34%)  Greatly influenced by mass media and opinion leaders  By virtue of their numbers, they begin to form a new norm  Lots of contact with peers, but don’t hold leadership positions.

65. Categories of Adopters  Late Majority (34%)  Skeptical of change  Tend to wait until an innovation is established as a norm before adopting  Motivation is greatly influenced by peers  Don’t like risk and uncertainty

66. Categories of Adopters  Laggards (16%)  Very traditional and conservative  Tend to have less education and lower SES  Socially and geographically mobile  Narrow and restricted communication networks  Suspicious of innovations and adverse to risk

67. Determinants of Diffusion’s Speed and Extent  Is the innovation better than what it will replace?  Does the innovation fit with the intended audience?  Is the innovation easy to use?  Can the innovation be tried out before adopting?  Are the results of the innovation observable and easily measured?

68. Diffusion of Innovations Theory ConceptDefinitionApplication Relative advantageThe degree to which an innovation is seen as better than the idea, practice, program, or product it replaces. Point out unique benefits; monetary value convenience, time saving, prestige, etc. CompatibilityHow consistent the innovation is with values, habits, experience, and needs of potential adopters. Tailor innovation for the intended audience’s values, norms, or situation. ComplexityHow difficult the innovation is to understand and/or use. Create program/idea/product to be uncomplicated, easy to use and understand. TrialabilityExtent to which the innovation can be experimented with before a commitment to adopt is required. Provide opportunities to try on a limited basis, e.g., free samples, introductory sessions, money-back guarantee. ObservabilityExtent to which the innovation provides tangible or visible results. Assure visibility of results: feedback or publicity. NIH, Theory at a Glance

69. Summary of Theories TheoryFocusKey Concepts Health Belief Model Individuals’ perceptions of the threat posed by a health problem, the benefits of avoiding the threat, and factors influencing the decision to act. Perceived susceptibility Perceived severity Perceived benefits/barriers Cues to action Self-Efficacy Transtheoretical Model Individuals’ motivation and readiness to change a problem behavior. Pre-contemplation Contemplation Preparation Action Maintenance Theory of Planned Behavior Individuals’ attitudes toward a behavior, perceptions of norms, and beliefs about the ease or difficulty of changing. Behavioral intention Attitude Subjective norm Perceived behavioral control NIH, Theory at a Glance

70. Summary of Theories continued TheoryFocusKey Concepts Social Cognitive TheoryPersonal factors, environmental factors, and human behavior exert influence on each other. Reciprocal determinism Behavioral capacity Expectations Self-efficacy Observational learning Reinforcements Diffusion of Innovations Theory How new ideas, products, and practices spread within a society or form one society to another. Relative advantage Compatibility Complexity Trialability Observability NIH, Theory at a Glance

71. A few more pieces  Predisposing, Reinforcing, and Enabling Factors  Barriers to change  PRECEDE/PROCEED behavioral diagnosis phase

72. Predisposing Factors  Provide the rationale or motivation for a person or group to act  KAB (knowledge, attitudes, beliefs)  Personal preferences  Existing skills  Self-efficacy beliefs  Individual level theories  Intrapersonal are most appropriate for addressing these factors.

73. Reinforcing Factors  Factors that provide reinforcement and reward for actions and encourage repetition of the action  Social support  Peer influence  Significant others (family, spouse, partner)  Employers, teachers, health providers, community leaders, decision-makers

74. Enabling Factors  Factors that provide the means or make the action possible.  Availability of programs or services or skills training  Accessibility of programs or services or skills training

75. Writing Objectives  Objectives start with the word “to” followed by an action verb.  Specify a single, key action to be accomplished  The What / how much  Specifies a target date  The When  Avoids the How and Why  Realistic and attainable

76. Objectives  S: specific  M: measurable  A: attainable  R: realistic  T: timely

77. Examples of objectives  To decrease soda intake by one soda a week and be soda free by December 1 st, 2012.  To increase running distance 1 mile every week in order to run a marathon on March 10 th, 2013.  To cook a new vegetable recipe once a week through December 5 th, 2012.